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October 2020 1.0 5 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: Hermelinda J. Canto Party/Vendor Contact Person: Luis Jimenez (son, English interpreter) <br />Contact Phone: 919-448-4099 Party/Vendor Address: 7721 Rogers Road City Chapel Hill State: NC Zip: 27516 <br />Department: Planning Amount: $0 Purpose: Historic Rogers Road Area - LMI Sewer Connection Initiative - Property <br />Owner Qualification Agreement for 7721 Rogers Road Budget Code(s): #61370035-880020-10054 Vendor # N/A - <br />property owner will not receive payments from Orange County (N/A if new vendor) Vendor is a BOCC consultant? <br />Yes No Contract Type: (Check one) New Renewal Amendment Effective Date April 20, 2021 <br />Approved by Board Yes No Agenda Date: <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work on <br />this project has not been initiated prior to execution of the agreement: <br /> <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br />Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br />agreement have already begun or been completed please briefly describe the nature of the emergency condition that <br />was addressed: <br /> <br />Information Technologies <br /> <br />(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is <br />approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br /> <br /> <br />DocuSign Envelope ID: C9EC122D-201B-42CD-8C09-AEE84F831F99 <br />4/16/2021 <br />4/16/2021 <br />4/22/2021 <br />4/22/2021